Checklist as a Memory Externalization Tool during a Critical Care Process

Abstract

We analyzed user interactions with a paper-based checklist in a regional trauma center to inform the design of digital cognitive aids for safety-critical medical teamwork. An initial review of paper checklists from actual trauma resuscitations revealed that trauma team leaders frequently wrote notes on the checklist. To understand this notetaking practice, we performed content analysis of 163 checklists collected over the period of four months. We found nine major categories of information that leaders recorded during resuscitations, including patient values, physical assessment findings, and pre-hospital information. An analysis of types and amount of notes written by leaders of different experience levels showed that more experienced leaders recorded more patient values and physical findings, while less experienced leaders recorded more notes about their activities and task completion status. These findings suggested that a checklist designed for a high-risk, fast-paced medical event has evolved into a dual function tool, serving both as a compliance and memory aid. Based on these findings, we derived requirements for designing digital cognitive aids to support safety-critical medical teamwork.

Figure 1.

Trauma resuscitation checklist with physician’s notes.

Figure 2.

(a) The frequency an item was checked off. (b) The number of times a note was taken for frequently checked items. Items in (a) and (b) are ordered by frequency, but the same item may be in different positions in (a) and (b). (c) Scatterplot of the relationship between the frequencies of item checking and their corresponding notes.

Figure 3.

Instances of recorded vital signs trends: Oxygen saturation (top); Blood pressure (bottom).

Figure 4.

Notes about physical findings.

Figure 5.

Pre-hospital information notes for a transfer patient.

Figure 6.

Care plan notes examples.

Figure 7.

Treatment notes (left) and laboratory results notes (right).

Figure 8.

Experience-based fractions of leaders taking notes on the checklist.

Figure 9.

Experience-based differences in the types of notes taken on the checklist.